Last updated March 15, 2022

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

Summary of Recommendations

DIAGNOSIS

When examining a patient with suspected carpal tunnel syndrome (CTS), clinicians should use Semmes-Weinstein monofilament testing (SWMT), using the 2.83 or 3.22 monofilament as the threshold for normal light touch sensation and static 2-point discrimination on the middle finger to aid in determining the extent of nerve damage. In those with suspected moderate to severe CTS, clinicians should assess any radial finger using the 3.22 filament as the threshold for normal. Semmes-Weinstein monofilament testing should be repeated by the same provider. (A)
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In those with suspected CTS, clinicians should use the Katz hand diagram, Phalen test, Tinel sign, and carpal compression test to determine the likelihood of CTS and interpret examination results in the context of all clinical exam findings.
Clinicians should assess and document patient age (older than 45 years), whether shaking their hands relieves their symptoms, sensory loss in the thumb, the wrist ratio index (greater than 0.67), and scores from the Boston Carpal Tunnel Questionnaire symptom severity scale (CTQ-SSS) (greater than 1.9). The presence of more than 3 of these clinical findings has shown acceptable diagnostic accuracy. (B)
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There is conflicting evidence on the diagnostic accuracy and clinical utility of the upper-limb neurodynamic tests, scratch-collapse test, and tests of vibration sense in the diagnosis of CTS, and therefore no recommendation can be made. (D)
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EXAMINATION – OUTCOME MEASURES: ACTIVITY LIMITATIONS/SELF-REPORTED MEASURES

Clinicians should use the CTQ-SSS to assess symptoms and the Boston Carpal Tunnel Questionnaire functional scale (CTQ-FS) or the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire to assess function when examining patients with CTS. Clinicians should use the CTQ-SSS to assess change in those undergoing nonsurgical management. (B)
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EXAMINATION – ACTIVITY LIMITATIONS/ PHYSICAL PERFORMANCE MEASURES

Clinicians may use the Purdue Pegboard (PPB) or the Dellon-modified Moberg pick-up test (DMPUT) to quantify dexterity at the onset of treatment and compare scores with established norms. Clinicians should not use the PPB test, JebsenTaylor Hand Function Test, or the Nine-Hole Peg Test to assess clinical change following carpal tunnel release (CTR) surgery. Clinicians may use the DMPUT to assess change following CTR surgery. (C)
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EXAMINATION – ACTIVITY LIMITATIONS/ PHYSICAL IMPAIRMENT MEASURES

Strength Measures

Clinicians should not use lateral pinch strength as an outcome measure for patients with nonsurgically or surgically managed CTS. (A)
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Clinicians should not use grip strength when assessing short-term (less than 3 months) change in individuals following CTR surgery. (B)
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Clinicians may assess grip strength and 3-point or tip pinch strength in individuals presenting with signs and symptoms of CTS and compare scores with established norms. (C)
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There is conflicting evidence on the use of tip and 3-point pinch strength and abductor pollicis brevis muscle strength testing in individuals following CTR surgery. (D)
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Sensory and Provocative Measures

Clinicians should not use threshold or vibration testing to assess change in individuals with CTS undergoing nonsurgical management until more evidence becomes available. Clinicians may use the Phalen test to assess change in those with CTR surgery at long-term follow-ups. (C)
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There is conflicting evidence on the use of sensory measures, including 2-point discrimination and threshold testing, to assess change over time in patients with surgically managed CTS. (D)
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INTERVENTIONS – ASSISTIVE TECHNOLOGY

Clinicians may educate their patients regarding the effects of mouse use on carpal tunnel pressure and assist patients in developing alternate strategies, including the use of arrow keys, touch screens, or alternating the mouse hand. Clinicians may recommend keyboards with reduced strike force for patients with CTS who report pain with keyboard use. (C)
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INTERVENTIONS – ORTHOSES

Clinicians should recommend a neutral-positioned wrist orthosis worn at night for short-term symptom relief and functional improvement for individuals with CTS seeking nonsurgical management. (B)
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Clinicians may suggest adjusting wear time to include daytime, symptomatic, or full-time use when night-only use is ineffective at controlling symptoms in individuals with mild to moderate CTS. Clinicians may also add metacarpophalangeal joint immobilization or modify the wrist joint position for individuals with CTS who fail to experience relief. Clinicians may add patient education on pathology, risk identification, symptom self-management, and postures/activities that aggravate symptoms. (C)
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Clinicians should recommend an orthosis for women experiencing CTS during pregnancy and should provide a postpartum follow-up evaluation to examine the resolution of symptoms. (C)
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INTERVENTIONS – BIOPHYSICAL AGENTS

Clinicians may recommend a trial of superficial heat for short-term symptom relief for individuals with CTS. (C)
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Clinicians may recommend the application of microwave or shortwave diathermy for short-term pain and symptom relief for patients with mild to moderate idiopathic CTS. (C)
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Clinicians may offer a trial of interferential current for short-term pain symptom relief in adults without pacemakers with idiopathic, mild to moderate CTS. As with all electrical modalities, contraindications should be taken into consideration before choosing this intervention. (C)
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Clinicians should not use low-level laser therapy or other types of nonlaser light therapy for individuals with CTS. (B)
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Clinicians should not use thermal ultrasound in the treatment of patients with mild to moderate CTS. (C)
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There is conflicting evidence on the use of nonthermal ultrasound in the treatment of patients with mild to moderate CTS, and therefore no recommendation can be made. (D)
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Clinicians should not use iontophoresis in the management of mild to moderate CTS. (B)
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Clinicians may perform phonophoresis within nonsurgical management of patients with mild to moderate CTS for the treatment of clinical signs and symptoms. (C)
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Clinicians should not use or recommend the use of magnets in the intervention for individuals with CTS. (B)
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INTERVENTIONS – MANUAL THERAPY TECHNIQUES

Clinicians may perform manual therapy, directed at the cervical spine and upper extremity, for individuals with mild to moderate CTS in the short term. (C)
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There is conflicting evidence on the use of neurodynamic mobilizations in the management of mild to moderate CTS. (D)
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INTERVENTIONS – THERAPEUTIC EXERCISE

Clinicians may use a combined orthotic/stretching program in individuals with mild to moderate CTS who do not have thenar atrophy and have normal 2-point discrimination. Clinicians should monitor those undergoing treatment for clinically significant improvement. (C)
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Recommendation Grading

Overview

Title

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

Authoring Organization

Publication Month/Year

April 30, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Describe evidence-based practice, including diagnosis, prognosis, intervention, and assessments of outcomes for musculoskeletal disorders. Classify and define common musculoskeletal conditions using the World Health Organization's terminology related to impairments of body function and body structure, activity limitations, and participation restrictions. Identify interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions associated with common musculoskeletal conditions. Identify appropriate outcome measures to assess changes resulting from physical therapy interventions in body function and structure as well as in activity and participation of the individual. Provide a description to policy makers, using internationally accepted terminology, of the practice of orthopaedic physical therapists and hand rehabilitation. Provide information for payers and claims reviewers regarding the practice of orthopaedic and hand therapy for common musculoskeletal conditions. Create a reference publication for clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regarding the best current practice of orthopaedic physical therapy and hand rehabilitation.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Emergency care, Outpatient

Intended Users

Physical therapist, occupational therapist, athletics coaching, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Rehabilitation, Management, Treatment

Diseases/Conditions (MeSH)

D009408 - Nerve Compression Syndromes

Keywords

carpal Tunnel Syndrome, Carpal Tunnel Syndrome, Hand pain, hand compression, nerve compression, carpal_tunnel_syndrome